Functional Behavioral Assessment Worksheet

Transcription

1 Functional Behavioral Assessment Worksheet Student Name (DOB) Grade Today s Date School District/Building FBA Team Members Indirect Record Review Behavior Logs/ Discipline Reports Structured Interviews w/ Reports from Collection Rating Scales Direct Consultant Observation ABC Data Collection Staff Direct Observation Other Direct Data Tasks for completing an FBA Who? By when? 1. Obtain parental permission (if applicable) 2. Records Review Academic Medical Discipline (SWIS) 3. Schedule/ conduct interviews (teachers/ staff) 4. Schedule / conduct interviews with student and parents (if necessary) 5. Schedule / conduct observation ABC Scatter plot 6. Summarize data and develop hypothesis statement 7. Develop Behavior Support Plan 8. Evaluate Plan.

2 Functional Behavioral Assessment Student-Assisted Interview Form Interviewer: Date Respondent 1. Tell me about things that you like/ dislike at school, home, and other places. 2. Tell me about things that seem to be going well or not so well at school, home, and other places. 3. Tell me about the subject or class you like most or least. Why? 4. Tell me about when you seem to have the most or least problems (where you are; what time of day; who else is around you). 5. Tell me what happens when you [target behavior]. What does the teacher say or do. What do the other students say or do? 6. Do you remember what were you thinking right before you [target behavior]?

3 Functional Behavioral Assessment Teacher Interview Form Interviewer(s) Date(s) Student(s) Respondent(s) 1. Describe the behavior of Concern 2. How often does the behavior occur? How long does it last? How intense is the behavior? 3. What is happening when the behavior occurs? 4. When/where is the behavior most/least likely to occur? 5. With whom is the behavior most/least likely to occur? 6. What conditions are most likely to precipitate ( set off ) the behavior? 7. How can you tell the behavior is about to start?

4 8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and student responses. 9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this way? What does the student get or avoid? 10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate within the social/environmental context? 11. What other information might contribute to creating an effective behavioral intervention plan (e.g., under what conditions does the behavior not occur?) 12. Who should be involved in the planning and implementation of the behavioral intervention plan?

5 Functional Assessment Checklist for Teachers and Staff (FACTS-Part A) Step 1 Student/ Grade: Date: Step 2 Step 3 Student Profile: Please identify at least three strengths or contributions the student brings to school. Problem Behavior(s): Identify problem behaviors Tardy Fight/physical Aggression Disruptive Theft Unresponsive Inappropriate Language Insubordination Vandalism Withdrawn Verbal Harassment Work not done Other Verbally Inappropriate Self-injury Describe problem behavior: Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely. Step 4 Schedule (Times) Activity Likelihood of Problem Behavior Specific Problem Behavior Low High Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities (conditions) with ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-Part B for each routine identified. Step 5 March, Horner, Lewis-Palmer, Brown, Crone, Todd & Carr (2000) 4/24/00

6 Functional Assessment Checklist for Teachers & Staff (FACTS-Part B) Step 1 Student/ Grade: Interviewer: Date: Respondent(s): Step 2 Routine/Activities/Context: Which routine(only one) from the FACTS-Part A is assessed? Routine/Activities/Context Problem Behavior(s) Provide more detail about the problem behavior(s): Step 3 What does the problem behavior(s) look like? How often does the problem behavior(s) occur? How long does the problem behavior(s) last when it does occur? What is the intensity/level of danger of the problem behavior(s)? Step 4 Step 5 Step 6 What are the events that predict when the problem behavior(s) will occur? (Predictors) Related Issues (setting events) Environmental Features illness Other: drug use negative social conflict at home academic failure reprimand/correction structured activity physical demands unstructured time socially isolated tasks too boring with peers activity too long Other tasks too difficult What consequences appear most likely to maintain the problem behavior(s)? Things that are Obtained Things Avoided or Escaped From adult attention Other: peer attention preferred activity money/things hard tasks Other: reprimands peer negatives physical effort adult attention SUMMARY OF BEHAVIOR Identify the summary that will be used to build a plan of behavior support. Setting Events & Predictors Problem Behavior(s) Maintaining Consequence(s)

7 Step 7 Step 8 How confident are you that the Summary of Behavior is accurate? Not very confident Very Confident What current efforts have been used to control the problem behavior? Strategies for preventing problem behavior Strategies for responding to problem behavior schedule change Other: seating change curriculum change reprimand office referral detention Other: March, Horner, Lewis-Palmer, Brown, Crone, Todd, & Carr (2000) 4/24/00

8 The Functional Assessment Checklist for Teachers and Staff (FACTS): Instructions The FACTS is a two-page interview used by school personnel who are building behavior support plans. The FACTS is intended to be an efficient strategy for initial functional behavioral assessment. The FACTS is completed by people (teachers, family, clinicians) who know the student best, and used to either build behavior support plans, or guide more complete functional assessment efforts. The FACTS can be completed in a short period of time (5-15 min). Efficiency and effectiveness in completing the forms increases with practice. How to Complete the FACTS-Part A Step #1: Complete Demographic Information: Indicate the name and grade of the student, the date the assessment data were collected, the name of the person completing the form (the interviewer), and the name(s) of the people providing information (respondents). Step #2: Complete Student Profile Begin each assessment with a review of the positive, and contributing characteristics the student brings to school. Identify at least three strengths or contributions the student offers. Step #3: Identify Problem Behaviors Identify the specific student behaviors that are barriers to effective education, disrupt the education of others, interfere with social development or compromise safety at school. Provide a brief description of exactly how the student engages in these behaviors. What makes his/her way of doing these behaviors unique? Identify the most problematic behaviors, but also identify any problem behaviors that occur regularly. Step #4: Identify Where, When and With Whom the Problem Behaviors are Most Likely A: List the times that define the student s daily schedule. Include times between classes, lunch, before school and adapt for complex schedule features (e.g. odd/even days) if appropriate. B: For each time listed indicate the activity typically engaged in during that time (e.g. small group instruction, math, independent art, transition).

9 C: Use the 1 to 6 scale to indicate (in general) which times/activities are most and least likely to be associated with problem behaviors. A 1 indicates low likelihood of problems, and a 6 indicates high likelihood of problem behaviors. D: Indicate which problem behavior is most likely in any time/activity that is given a rating of 4, 5 or 6. Step #5: Select Routines for Further Assessment Examine each time/activity listed as 4, 5 or 6 in the Table from Step #4. If activities are similar (e.g. activities that are unstructured; activities that involve high academic demands; activities with teacher reprimands; activities with peer taunting) and have similar problem behaviors treat them as routines for future analysis. Select between 1 and 3 routines for further analysis. Write the name of the routine, and the most common problem behavior(s). Within each routine identify the problem behavior(s) that are most likely or most problematic. For each routine identify in Step #5 complete a FACTS-Part B How to Complete the FACTS-Part B Step #1: Complete Demographic Information: Identify the name and grade of the student, the date that the FACTS-Part B was completed, who completed the form, and who provided information for completing the form. Step #2: Identify the Target Routine List the targeted routine and problem behavior from the bottom of the FACTS-Part A. The FACTS-Part B provides information about ONE routine. Use multiple Part B forms if multiple routines are identified. Step #3: Provide Specifics about the Problem Behavior(s) Provide more detail about the features of the problem behavior(s). Focus specifically on the unique and distinguishing features, and the way the behavior(s) is disruptive or dangerous. Step #4: Identify Events that Predict Occurrence of the Problem Behavior(s) Within each routine what (a) setting events, and (b) immediate preceding events predict when the problem behavior(s) will occur. What would you do to make the problem behaviors happen in this routine?

10 Step #5: Identify the Consequences that May Maintain the Problem Behavior What consequences appear to reward the problem behavior? Consider that the student may get/obtain something they want, or that they may escape/avoid something they find unpleasant. Identify the most powerful maintaining consequence with a 1, and other possible consequences with a 2 or 3. Do not check more than three options. The focus here, is on the consequence that has the greatest impact. When problems involve minor events that escalate into very difficult events, separate the consequences that maintain the minor problem behavior from the events that may maintain problem behavior later in the escalation. Step #6: Build a Summary Statement The summary statement indicates the setting events, immediate predictors, problem behaviors, and maintaining consequences. The summary statement is the foundation for building an effective behavior support plan. Build the summary statement from the information in the FACTS-A and FACTS-B (Especially the information in Steps #3, #4, and #5 of the FACTS-B). If you are confident that the summary statement is accurate enough to design a plan move into plan development. If you are less confident, then continue the functional assessment by conducting direct observation. Procedures for completing the functional assessment, and for designing behavioral support are described in the following references. Step #7: Determine Level of Confidence Use the 1-6 scale to define the extent to which you, the interviewer or the team are confident that the summary statement is accurate. Confidence may be affected by factors such as (a) how often the problem behavior occurs, (b) how long you have known the focus person, (c) how consistent the problem behaviors are, (d) if multiple functions are identified, and (e) if multiple behaviors occur together Step #8: Define what has been done to date to prevent/control the problem behavior In most cases, school personnel will have tried some strategies already. List events that have been tried, and organize these by (a) those things that have been to prevent the problem from getting started, (b) those things that were delivered as consequences to control or punish the problem behavior (or reward alternative behavior).

11 ABC OBSERVATION FORM Student Name: Observer: Activity: Observation Date: Time: Class Period: ANTECEDENT BEHAVIOR CONSEQUENCE

12 ABC OBSERVATION FORM Student: Observer: Date: Time: Activity: Context of Incident: Antecedent: Behavior: Consequence: Comments/Other Observations:

13 ABC OBSERVATION FORM Student Name: Ben S. Observation Date: 10/5 Observer: R. Day Time: 9:40-9:55 a.m. Activity: disruptive behavior Class Period: 3 ANTECEDENT BEHAVIOR CONSEQUENCE Teacher begins tells students to look at board. Ben looks around room and at other kids. Teacher continues lesson; ignores Ben. Teacher puts examples on board and asks class to work problems. Ben looks around and calls to Fran. Teacher asks for quiet. Teacher tells class to do 5 more problems. Ben turns around and pokes Fran with pencil. Teacher tells Ben, get to work, NOW! Ben calls out, this is too hard. He throws worksheet and book on floor. Teacher demands that Ben come forward, get a hall pass, and go to the office.

14 APPENDIX B ABC OBSERVATION FORM Student Name: Trish Observer: Ms. Pasillas Activity: disruptive behavior on the playground Observation Date: 10/5 Time: 9:40-9:55 a.m. Class Period: 3 ANTECEDENT BEHAVIOR CONSEQUENCE Trish joins group of 4 girls playing catch. Ball is again thrown to Karen. Karen begins to walk away with the ball. Trish waits for ball to be thrown to her. Trish yells Throw it to me! Trish yells I said throw it to me you jerk! Trish runs up behind Karen and kicks her saying Give it to me damn it! Girls do not throw ball to Trish. Girls throw ball to her, she misses it and another girl, LuAnne catches it and throws it to Sandy. Karen cries. Trish takes the ball.

15 FUNCTIONAL ASSESSMENT SCATTERPLOT Student: Grade: School: Date(s): Observer(s): Behavior(s) of concern: ACTIVITY TIME DAY OF THE WEEK Monday Tuesday Wednesday Thursday Friday TOTAL TOTAL

16 FUNCTIONAL ASSESSMENT SCATTERPLOT Student: Myree Grade: 6 th School: John B. Lynn Date(s): 10/4/97 to 10/8/97 Observer(s): Dennis Behavior(s) of concern: disrupts class w/inappropriate comments and verbal threats directed at peers. Setting: ACTIVITY TIME MATH 9:20-10:10 SCIENCE 10:10-11:00 SOCIAL 11:00- STUDIES 11:50 DAY OF THE WEEK TOTAL Monday Tuesday Wednesday Thursday Friday II IIII III II IIII 15 I II I I II 7 II IIII IIII I IIII 15 TOTAL

17 PROBLEM BEHAVIOR QUESTIONNAIRE Student Teacher Date Student Behavior: Keeping in mind the problem behaviors identified in the Teacher Interview. Circle the frequency at which each of the following statements is true. Never 10% of 25% of 50% of 75% of 90% of Always time time time time time 1. Does the problem behavior occur and persist when you make a request to perform a task? When the problem behavior occurs, do you redirect the student to get back to task or follow the rules? During a conflict with peers, if the student engages in the problem behavior, do peers leave the student alone? When the problem behavior occurs, do peers verbally respond or laugh at the student? Is the problem behavior more likely to occur following a conflict outside the classroom? (e.g. bus write-up) Does the problem behavior occur to get your attention when you are working with another student? Does the problem behavior occur in the presence of specific peers? Is the problem behavior more likely to continue to occur throughout the day following an earlier episode? Does the problem behavior occur during specific academic activities? Does the problem behavior stop when peers stop interacting with the student? Does the behavior occur when peers are attending to other students? If the student engages in the problem behavior, do you provided one-to-one instruction to get the student back on task? Will the student stop doing the problem behavior if you stop making requests or end an academic activity? If the student engages in the problem behavior, do peers stop interacting with the student? Is the problem behavior more likely to occur following unscheduled events or disruption in classroom routines?

18 Student Problem Behavior Questionnaire Profile Peers Peers Adults Adults Setting Events Escape Attention Escape Attention Question: Developed by Lewis, Timothy J., Scott, Terrance M., Sugai, George. (1994) Diagnostic, 19 (2-3),

19 FINAL REPORT STUDENT ASSISTANCE TEAM XY HIGHSCHOOL FUNCTIONAL ASSESSMENT OF BEHAVIOR DATE: NAME: BIRTH DATE AGE: PRIMARY LANGUAGE: SCHOOL: GRADE: TEACHER: EVALUATOR REASON FOR REFERRAL Name was referred to the evaluator by REFERRAL SOURCE. It is our hope that this evaluation will aid in determining the function of the following behavior problem: PROBLEM BEHAVIOR AS DEFINED BY REFERRAL SOURCE. From this assessment, a behavior intervention plan will be developed. These behaviors have interfered with Name's achievement of his/her academic goals and have resulted in suspension/ failure from school. From this assessment a behavior intervention program will be developed by the SAT. At the time of referral Name displayed the following behaviors: (list behaviors as identified by the referral source) ASSESSMENT PROCEDURES BACKGROUND INFORMATION Data Collection Methods Used: Indirect Direct Record Review Behavior Logs/ Discipline Reports Structured Interviews w/ Reports from Rating Scales Consultant Observation ABC Data Collection Staff Direct Observation Other Direct Data Collection Name is an age-year-old, grade-grade-sex who attends School. She/He has attended School since Month, Year. School attendance has been attendance pattern.

20 Behavioral History From interviews (with) and record review it was learned that this behavior problem has previously been displayed. (Describe history of behavior problem). Previous interventions attempted to help manage this behavior problem have included the following: (Describe prior interventions). The following intervention components appear to have some potential and should be considered when developing Name's behavior intervention plan: (Describe previously attempted interventions that were helpful). Alternatively, the following components appear do not appear to have been helpful and should be avoided: (Describe previously attempted interventions that were not helpful and should be avoided). From this behavioral history a tentative hypothesis of the function(s) of the problem behavior was (were) developed. It would appear that this behavior is positively- and/or negatively reinforcing. Specifically, because of (Behavior problem) Name appears to obtain (List what the behavior gets for the student). and/or Specifically, because of (Behavior problem) Name appears to escape or avoid (Report what the behavior allows the student Hypothesized Function of the Target Behavior Based on this, what FUNCTION might the behavior be serving? (What is the student GETTING or AVOIDING by engaging in the behavior) ACCESS / GET Something INTERNAL Cognitive Emotional Communication Control Revenge Sensory Auditory Visual OTHER EXTERNAL Attention Tangibles Activities Other AVOID/ESCAPE Something Cognitive Emotional Physiological Sensory Auditory Visual OTHER Setting Task Activity Person(s) Academic Subject OTHER Replacement Behaviors From interviews (with) it was determined that (State incompatible behavior) was a positive alternative behavior incompatible with the target behavior. Specifically, (Provide a clear behavioral description of the replacement behavior). This behavior would appear to obtain the same goal as the target behavior.

21 PROBLEM IDENTIFICATION: Describe the BEHAVIOR(s) of concern (observable and measurable): _ Consequences of the Replacement Behavior Currently, consequences of Name's (Replacement behavior) include (List the result or consequence of the replacement behavior for the student). Potential reinforcers for the replacement behavior may include (From hypothesized function of behavior, list possible reinforcers that may increase the replacement behavior). Consequences Maintaining the Behavior/FUNCTION: What events typically FOLLOW the behavior? (See ABC Data) Behavior Intensity (How severe is the behavior?) This data helps to document the severity of the target behavior. At the time of this assessment, the behavior was rated as being a Level? (On a scale of 1 to 5, with 5 being the most severe) on a disruptive behavior rating rubric. This level of behavioral severity is defined as follows: Level 1, Behavior is confined only to the observed student. Level 2, Behavior disrupts others in the student s immediate area. Level 3, Behavior disrupts everyone in the class. Level 4, Behavior disrupts other classrooms or common areas of the school. Level 5, Behavior causes or threatens to cause physical injury to Name or others. Behavior Duration (How long does the behavior last?) Duration data reflects the time that the behavior was expressed from beginning to end. For the purposes of baseline data collection, the behavior was judged to begin when Name (State beginning criteria) and to end when (State ending criteria). Data from each of the (state # of days) baseline data days was as follows: Date Duration During the data collection period Name displayed the behavior for a total (Total amount of time). On average the behavior lasted (Average).

22 ESTABLISHING OPERATIONS THAT MAY INFLUENCE BEHAVIOR (SETTING EVENTS) Also referred to as setting events or ecological variables, these events typically occur the morning of or evening before a given behavior is displayed. They make it more or less likely that a behavior will be judged as reinforcing (e.g., a student who is hungry will, find behaviors that obtain food more reinforcing). They also influence the likelihood that a behavior will occur (e.g., a student who is tired is more likely to display task avoidance behaviors). These events were identified by rating scales, observation, interview, and/or record review. Antecedent / Setting Events (Contextual Variables): What conditions tend to SET OFF the behavior (look for patterns in ABC Data)? For whom is the behavior a problem? For whom is the behavior NOT a problem? Where does the behavior occur MOST often? LEAST often? At what time of the day does the behavior occur MOST often? LEAST often? During what activities does the behavior occur MOST often? Least often? Are the expectations for this student REASONABLE (describe)? Are the adults in the student s environment CONSISTENT (i.e: similar expectations, directions, discipline strategies. Please describe) Are the adults in the student s environment RESPECTFUL of the student s values/needs? Additional ANTECEDENTS / SETTING EVENTS Checklist (check/describe most relevant contextual variables) Medical/Emoti onal Environmental Social/ Curricular/ Instructional Personal Interactional Auditory Social Task Difficulty Choice- Hunger/Thirst Expectations Making Restroom Visual Opportunity Task Length Communica

23 w/ peers tion Health Transition Teacher / Rate of Presentation Emotional Staff Medication Predictability Proximity Delivery of Instruction Routine Dependent Diet Class Size Behavior of Peers Level of Assistance Personal Likes/Dislikes Sleep Seating Necessary Social Skills Meaningful Coping Skills Clothing Change of Staff Variation of Material DESCRIBE:

24 Behavior Support Plan, Summary Statement of the Problem Behavior Pathway Alternative Behavior Maintaining consequences Setting event Problem Behavior Maintaining consequences Function Desired Behavior SUMMARY This assessment was designed to help determine the function of the following serious behavior problem: (Target Behavior). From this assessment it has been determined that the following events are establishing operations for this behavior: (List events). Immediate antecedents or triggers of the behavior appear to include (List Antecedents). The immediate consequences of Name s behavior problem typically include (Consequences). Given this result of his/her behavior it is suggested that the problem behavior is negatively and/or positively reinforcing. In other words, when Name engages in (Target Behavior) he/she is likely to obtain (Positive Reinforcers) and/or escape and/or avoid (Negative Reinforcers).

25 RECOMMENDATIONS (Try to avoid combining recommendations. Be specific in each recommendation. Use scripting for teachers when necessary. They should allow individuals not familiar with the student, the classroom, or even your assessment data to implement what you recommend) From this functional assessment of behavior the following behavior intervention program recommendations are offered: (Positive alternative behaviors) List strategies that make the problem behaviors irrelevant, ineffective, & inefficient Predictor (setting event) Strategies (how to modify the setting events) e.g: Does not understand work. Instructional Strategies e.g: 1. Pre teach work at beginning of class if there is available time. 2. Teacher report to Mentor or Guidance Counselor regularly on homework completion. Consequence Strategies 1.Take a moment after/before class to thank Johnny for doing work. 2. Be sure to thank Johnny if he asks for help with work. Behavior Modifications (replace problem behaviors) e.g: Blows up at teacher 1. Say to Johnny, your behavior right now is inappropriate. Then give him the option to either take walk to the drink fountain and return within 2 minutes (If you are not back by then, you will be reported to the office) or to calm down and return to his seat. 2. If refuses to cooperate, follow standard classroom discipline procedure for expressed behavior. 1. If Johnny speaks with the teacher after class, thank him for taking the time to calm down and speak about the matter. 2. If Johnny goes a week resolving disputes with teachers in a reasonable manner, then notify Mentor/Guidance to reward him with drink/snack.

26 QUALITY OF LIFE INTERVENTIONS The following interventions are geared towards improving the student s life outside school in his natural settings at home and social events. These types of interventions will ensure that NAME will have a consistent reinforcement pattern across the board. Personal Modifications: (modifications the student can do at home and /or social settings in order to achieve the desired goals/ desired behaviors) Check & Connect Monitoring Sheet Month Student ID School Monitor Chec k M T W T h F M T W T h F M T W T h F M T W T h F M T W T h F Hig h Risk For Mon th Tardy Skip Absent Behavi or Referr al Detent ion In school suspen sion Out of school suspen sion onnect Failing Classe s / behin d in Credit s D s F s Classes Passed out of Total. Credits earned out of Total Basic Shared general info

27 Provided regular feedback Discussed staying in school Problem solved about risk Intensive Arranged for alternative to suspension Contracted for behavior or grades Communicated with parents Made special accommodations Participated in Community Service Participated in school sponsored activity Participated in social skills group Worked with tutor or mentor Other:

28 Family modification: (modifications that parents can do at home in order to achieve the desired goals/ desired behaviors) Parent/Guardian SAT member Other staff member involved General Education Teacher Student

29 Behavior Support Plan Review Student Grade School Date SAT monitoring member 1. Review each task on the BSP Implementation plan to identify whether all tasks are being implemented successfully answer below under REVIEW DATA Data Collected Scatter-plot, point card, etc. Summary of the data # of occurrences/ patterns/ points earned out of possible points) Evaluation Decision Goal Attained/ Reinforcement Earned Is Plan Being Implemented? Is Plan Making a Difference? MODIFICATIONS TO THE BSP IMPLEMENTATION PLAN Tasks Person Responsible By When Was task Completed consistently? Evaluation Decision Monitor, Modify, or Discontinue Date & Time of the Next BSP Review meeting Parent/Guardian SAT member Other staff member General Education Teacher